- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,722.98 / $1,722.98 / $1,969.11
| Facility | | $1,722.98 | $1,722.98 | $1,969.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,722.98 / $1,969.11
| Professional | | $1,640.93 | $1,722.98 | $1,969.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.32 / $5.32 / $5.32
| Professional | | $5.32 | $5.32 | $5.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,640.93
| Facility | | $1,640.93 | $1,640.93 | $1,640.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,640.93
| Professional | | $1,640.93 | $1,640.93 | $1,640.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $25.00 / $50.00
| Professional | | $17.00 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,510.08 / $1,640.93 / $2,133.21
| Professional | | $1,510.08 | $1,640.93 | $2,133.21 |